The Care Quality Commission
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Archived: Kensington Park Surgery

Overall: Good read more about inspection ratings

157 Edge Lane, Edge Hill, Liverpool, Merseyside, L7 2AB (0151) 295 8770

Provided and run by:
SSP Health Ltd

Important: This service was previously managed by a different provider - see old profile

All Inspections

29 October 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an inspection at Kensington Park Surgery in October 2014 and found breaches of regulations relating to the safe, effective, well – led and responsive delivery of patient services. The overall rating of the practice in October 2014 was inadequate and the practice was placed into special measures for six months. Following the October 2014 inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to safe, effective, caring, responsive and well-led services.

We carried out a further announced comprehensive inspection at the practice on 29 October 2015. This inspection was carried out to consider whether sufficient improvements had been made and to identify if the provider was now meeting the legal requirements and regulations associated with the Health and Social Care Act 2008. At the inspection in October 2015, we found the practice had made significant improvements and they were now meeting all of the regulations which had previously been breached. The ratings for the practice have been updated to reflect our findings. Specifically, we found the practice had improved systems in place for providing safe, well-led, effective, caring and responsive services. I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

The practice is rated as good overall, for providing safe, effective, caring, responsive and well led services.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment however the use of locum GPs provided challenges with regard to continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider should make improvement are :

  • Review the system used to monitor safeguarding requests for information and the practice responses to ensure all relevant information was held in patient records. The system should also ensure that all appropriate staff have access to safeguarding information.
  • Ensure that recruitment records for those staff not directly employed by the provider such as self-employed GPs contain information that demonstrates that they are physically and mentally fit to carry out their roles safely and competently.
  • Progress should be made with regard to plans for improving patient participation.

I confirm that this practice has improved sufficiently to be rated Good overall. This practice will be removed from special measures.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

15 October 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

This is the report of findings from our inspection of Kensington Park Surgery. SSP Health Limited is registered with the Care Quality Commission to provide primary care services.

We undertook a planned, comprehensive inspection on 15 October 2014 at the practice location in the Kensington Neighbourhood Health Centre. We spoke with patients, staff and the practice management team.

The practice was rated overall as Inadequate.

Our key findings were as follows:

  • Staff understood their responsibilities to raise concerns, and report incidents and near misses. However, when things went wrong, reviews and investigations were not sufficiently thorough and lessons learnt were not communicated widely enough to support improvement.
  • Feedback from patients showed they were overall happy with the care given by all staff. They felt listened to, treated with dignity and respect and had confidence in the GPs and nurses.
  • The practice reviewed the needs of their local population and engaged with the NHS Area Team and Clinical Commissioning Group (CCG) to secure service improvements where these were identified. Patients reported good access to the practice. There was an accessible complaints system with evidence demonstrating that the practice responded to issues raised.
  • Staff spoken with were clear about their working values and ethos and how important these were in working in an area of high deprivation.
  • Audits focused on medicines management and did not review other patient outcomes. We saw little evidence that audits were driving improvement in performance for patient outcomes. Multidisciplinary working was reportedly taking place but this was generally informal and record keeping was limited or absent.
  • We did not see transparent and open governance arrangements. This potentially could lead to ineffective systems to manage staff and to identify, monitor and manage risks to patients.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Review the systems for assessing and monitoring the quality and safety of service provision and take steps to ensure risks are managed appropriately. With particular regard to clinical auditing, serious events investigation and analysis.
  • Review the support and learning systems in place to support the staff team to learn and develop the competencies and skills required to carry out their roles safely. With particular regard to providing protected learning time and appropriate clinical supervision.
  • Review the system in place to maintain the security of prescriptions including the maintenance of records for auditing purposes.

In addition the provider should:

  • Review the system in place for complaints handling and investigation to ensure the most appropriately qualified member of staff undertakes the investigation and analysis of the information.
  • Review the systems in place to gain feedback from patients.

On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice